AN ice-affected train passenger who died during a journey to Albury had been held face down by train staff before he stopped breathing.
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Coroner Helen Barry was highly critical of TrainLink staff and police in her findings into the death of Afif Fakhouri, also known as Jeff, on September 9, 2014.
Mr Fakhouri, 37, had been travelling to the Border to visit his mother.
He had boarded the Sydney to Melbourne train at Campbelltown about 10.30pm on September 8.
Several passengers and staff reported Mr Fakhouri had been agitated, aggressive, acting bizzarely and making little sense during the journey.
Train driver Craig Stevens called the Junee rail control room about 3am requesting police assistance, but they did not attend.
Mr Fakhouri was given a formal direction to leave the train at Cootamundra station at 3.40am and had to be removed by the driver and three others.
He was held on the ground and several passengers heard him say he could not breathe.
Mr Fakhouri stopped breathing while being held down and could not be revived.
There were conflicting reports about how long he had been restrained for, with estimates varying from two minutes to 15 minutes.
An autopsy revealed Mr Fakhouri had died from methamphetamine intoxication and restraint.
High levels of the drug were found in his blood.
The coroner found his death was a result of “a cavalcade of poor judgements, inappropriate action and a failure to understand the risk involved” in removing and restraining him.
Ms Barry found Mr Fakhouri had exercised poor judgement by taking ice to a toxic level, police demonstrated poor judgement by failing to respond and train staff behaved in an inappropriate manner when removing him.
“What is particularly concerning is that it is unclear from the evidence of the train staff whether they now have an understanding of what action should be taken if such a situation should arise if the future,” she said.
“The evidence clearly established that train staff are regularly confronted with aggressive, difficult and or unpredictable passengers.
“There is a need for clarity.”
Prime7 News reported Mr Fakhouri had been planning to move to the Border to be closer to his family.
The coroner offered her condolences to the family.